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Based on observations during the Life Safety Code survey, it was noted that structural components of the facility were not properly protected from fire. Issues include structural steel /steel beams of the building and the beams located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction of Type II (222).

The findings are:

During the survey from 01/27/14 to 01/29/14 between 11:00 AM to 4:00 PM, observations were made above the suspended ceilings in the facility, in the mechanical areas and other areas where the structural beam was visible from the floor level. During the observation it was revealed that the I-beams and steel beams/steel web truss assemblies/ steel supporting the weight of the deck above in many places were not completely protected with a fire resistive material.

Few examples of some unprotected I-beams including but not limited to are:
i. Three spots on the structural beam above the double door in the lobby next to the staff conference room.
ii. Some spots on the structural beam in the electrical /ATS room.
iii. I-beam in the soiled utility room of the Day hospital missing was missing fire retardant in spots.
iv. I-beam was noted missing fire retardant in the storage room by the mutli-purpose room on second floor.
v. I-beam was noted missing fire retardant in the Electrical room by the multipurpose room on second floor.
vi. Electrical room#1215 was noted missing fire retardant in some areas of the i-beam.
vii- I-beam was noted missing fire retardant in the Mechanical room in compartment #3.

Findings were verified with Director of Facilities and Chief Engineer accompanying the surveyor during the survey.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1
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Based on observation it was noted that the facility did not ensure that Bulk Clean linen room which is considered as a hazardous area is safeguarded from other spaces, by smoke/fire resisting partitions and doors which are self-closing/ automatic-closing or have a sprinkler head, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

Findings include:

1. On 01/28/14 at 1:30 PM during the tour of the Bulk Main Clean linen storage room it was noted that the room is about 528 SF. This room was noted not protected by any rated wall or sprinkler. It is to be noted that due to the size of the room and the combustible nature of the linen, this area is consider hazardous.

2. Facility has some areas identified in the floor plan being protected by one hour rating such as the IT closet in some compartment #6. This room was noted not having a fire rated door and had penetrations in the wall. As per Director of Facilities, the facility is not considering this areas as hazardous. It could explained to the surveyor why there was discrepancy between the floor plan and the room.

Findings were verified with Director of Facilities and Chief Engineer.

Based on observations, the facility did not ensure that all exit passageways are maintained free of obstruction or impediments to full and instant use, in the case of fire or other emergency as per NFPA 101 200 section. 7.1.10.1.
Furthermore, NFPA 101 Sub-Section 7.5.1.1 requires that ' Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times ' and Sub-Section 18.2.3.3 requires that ' Aisles, corridors and ramps required for exit access in a hospital shall not be less than 8 ft in clear and unobstructed width ' .

Findings include:

During the tour of the facility on 01/27/14 between 11:00 AM to 2;00 PM, it was noted that the Exit access/corridor outside the OPD exam rooms first floor were blocked with chairs and equipments on both side of the corridor. Similarly the Exit access by kitchen leading to the double door towards smoke compartment # 5 was impeded with two large line/trash 32 gallon and more containers

Such arrangement compromises the full instant use of the means of egress to the Exit.

Findings were verified with Director of Facilities and Chief Engineer.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning / evaluation of fire drills were done as per NFPA 101.

Findings include:

1. A review of the fire drill record on 01/30/14 at 2:00 PM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "pass" or "fail".

Review of fire drill records indicated that the facility did not conduct fire drills that include 'simulation of various types of emergency fire conditions' to ensure that each staff has a full and clear understanding of the facility's fire safety plan and how to execute it successfully under the varying conditions.

The fire drills checklist or report did not indicate under what scenario the fire drill was initiated.

2. The facility's fire drill records did not include staff sign-in sheets, although facility has a template in their policy to get all staff sign-in. Furthermore the facility failed to document in the records, a critique of the drill, the staff's fire drill response, and the staff knowledge of evacuation procedure to ensure that the staff was fully aware of fire drill/evacuation protocols.

3. Facility's policy titled 'Fire Plan-Code Red' indicated the use of 'code red' when the alarm is activated at pull station or by other fire alarm components such as detectors or flow devices. The policy was not written as per NFPA.19.7.2.3 which states that:
All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Therefore the use of verbal 'Code Red' to alert the staff was not included in the policy along with the alert for location.


Findings were verified with the Director of Facilities and Chief Engineer.

4. During review of the Disaster drill records on 01/30/14 at 3;00 PM, it was noted that the facility did not ensure that it incorporated the internal and external disaster scenarios respectively for its bi-annual disaster drills and conducted a comprehensive evaluation and assessment of the drill.
No policy was provided that indicates and defines step by step how a disaster drill will be conducted and evaluated.

Findings were verified with the Director of Quality Management.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1. During survey of facility from 01/27/14 to 01/29/14 between 10:30 AM to 3:45 PM, it was noted that in various areas of the facility ( including the in-patient unit on 1st and 2nd floor), the fire extinguishers were installed in the recess cabinet is such a way that its topmost portion was greater than the required 5 ft. (60 inches).

2. It was noted that there was no i fire extinguisher installed in the Main Lobby and in near vicinity where it could be easily accessible in case of fire/emergency.

All findings for high extinguishers were observed and verified with Director of Facilities and Chief Engineer.

Please Note: Section 1-6.3 of NFPA 10 states that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Furthermore Section 3-2.1 of NFPA 10 states
Minimal sizes of fire extinguishers for the listed grades of hazards shall be provided on the basis of Table 3-2.1, except as modified by 3-2.2. Fire extinguishers shall be located so that the maximum travel distances shall not exceed those specified in Table 3-2.1, except as modified by 3-2.2. (See Appendix E.)

Based on documentation review and staff interview, the facility failed to ensure that all fire dampers installed in all buildings at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair and installed in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.

Findings include:

1. On 01/30/14 at 11:30 AM, during review of 6 year fire/smoke damper assessment dated 11/29/13 , it was noted that 15 dampers in the building were 'unable to be tested'. No corrective action follow up report was provided.

The Director of Engineering stated that sometimes due to patients occupying an area or other reasons, the damper cannot be accessed, and therefore it is either not tested or cannot be accessed again after a deficiency is found. No documentation/policy was provided regarding what the facility intends to do in the interim to provide patient safety and how do they assess it.

2. During the inspection of the fire and smoke barriers in the facility from 01/27/14 to 01/29/14 between 11:30 AM to 4:00 PM, it was noted that that there were various ducts penetrating through the fire/smoke barrier. These ducts had fire sealant/caulking around it. The ducts were equipped with fire dampers.
NOTE: As per NFPA 90A 3-4.6 Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)

Therefore as per the above section, the code requires proper clearance for expansion should be maintained.
Furthermore NFPA 90A section 3-4.6.2* states that "Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer 's installation instructions".

The UL Building Material Directory also does not allow the space to be filled with any material.

Examples of fire retardant material around the ducts including but not limited to are:
i- The duct passing the fire/smoke barrier above the double door in the lobby near the staff conference room.
ii- The duct passing the fire/smoke barrier in the Mechanical Room of Smoke Compartment #3.
iii- The duct passing the fire/smoke barrier above the double door of Smoke Compartment #5 near the Kitchen.
iv- The duct passing the fire/smoke barrier near the above ceiling of room # 2184 area.

Thus facility did not ensure that the ducts with fire dampers do not have their angles sealed with fire caulking or sealant as that compromises the fire damper UL listing as per UL 555.

Findings were verified with the Director of Facilities and Chief Engineer at the time of observation.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6 . Furthermore, the fire/smoke barriers were not maintained for its full integrity.

Findings include:

During the tour of the facility from 01/27/14 to 01/28/14 between 11:00 AM to 4:00 PM, the fire/smoke barriers above the drop ceiling of the double doors were inspected for the integrity of smoke barriers. The rated walls of different areas were also inspected for integrity.

It was noted that the fire/smoke barriers that were penetrated by ducts, pipes, conduits, cables, wires for light, and other miscellaneous holes did not have complete seal all around to prevent passage of smoke from one compartment to the other or the devices used to prevent migration of smoke was not properly maintained.

Examples, including but not limited to include:

a. The HILTI sleeves in the fire/smoke barrier through which many cables were passing from one side of the barrier to the other, were noted not closed to seal and prevent passage of smoke. An example was in the fire/smoke barrier wall by room # 2184 and room #1208.

b. Gaps/holes made by wires and conduits were noted in the 1 hour fire wall above the double door in the smoke zone #5 by the kitchen.

c. Hot water pipes and black pipes were noted penetrating the rated wall in the boiler/chiller rooms. No fire retardant material/caulking was used to seal these gaps.

These findings were verified with the Director of Facilities and Chief Engineer.

Note: Section 8.3.6.1 of NFPA 101 states that:

Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

b. It shall be protected by an approved device that is designed for the specific purpose.

A. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered Mural Pavilion.

Findings include:

1. During the tour of the facility between 01/27/14 to 01/29/14 between 11:00 AM to 4:00 PM , it was noted that the elevator machine room ( both in the basement and first floor room #12341 did not have any sprinkler head. This compartment/newer side of the building is fully sprinklered and therefore as per NFPA 13 requires a sprinkler head in elevator machine room.

2. The electrical rooms in the newer built area ( near multpurpose room and inside the Day hospital suite) did not have any sprinkler heads instead any there was no information if as an alternative the walls of these two electrical room were rated or not.

Findings were observed and verified with Director of Facilities and Chief Engineer.

B. Based on observation, it was determined that the facility failed to test the emergency battery back up light for the generator.

Findings include:

On 01/28/14 at 3:00 PM , during the tour of the the generator room/trailer it was noted that the room had an emergency battery back up light as required by the code. However during the record review on 01/29/14 at 3:30 PM there were no records provided for the annual 90 minutes testing.

Director of Engineering stated that monthly 30 second test were done on them however annual 90 minute tests were not done.

Note: Subsection 5-3.1 of NFPA 110 requires that:
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Furthermore, Subsection 7.9.3 of NFPA 101 requires that:
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on document review and staff interview, the facility did not ensure that the TYPE 1 EES wiring for three branches of Emergency Generator was done as per NFPA 99 3.4.2.2.2 therefore ensure anything that is not required to be wired to Life Safety is accurately wired to either Critical Branch of Equipment Branch.

Findings include:

On 01/27/14 and 01/28/14 at between 11:00 AM to 4:00 PM, during the tour of the electrical rooms in the facility, the emergency generator's electrical panels were opened to rewire what items are wired in them.

During review of the Life Safety panel such as 2ELP-LS, EM-DR-2/EM-3, ELP-LS, EM-4, and EM-14 it was noted that there were items such as pressure sensor switch, pressure monitoring panel, receptacles of room ( such as 118, 120, 116, 112 and others), A/C univents, family room ice-machine, elevator sump pump, water meter pit heater and other similar items that were suppose to be wired to the equipment branch or critical branch however they were wired to Life safety branch

Therefore, the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Equipment Branch or Critical branch.

Furthermore, Director of Facilities stated that all areas of the facility may not be distributed and wired for three separate branches, although the emergency generator is supplying three branches and intended to be Type 1 EES since the facility takes care of patients on life support.


999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

Findings were verified with Director of Facilities and Chief Engineer.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Based on staff interview all electrical receptacles in patient care areas were not tested and maintained as per code.

Findings include:

On 01/29/14 at 3:45 PM , the Director of Facilities was requested to provide evidence that electrical receptacles in the patient care areas were tested. Director of Facilities stated there were no such records. The facility also did not have any policy and procedure in place regarding how often should the test be conducted.

NOTE:
As per NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas.

(1) Testing shall be performed after initial installation, replacement, or servicing of the device.

(2) Additional Testing shall be performed at intervals defined by documented performance data.

The codes of NFPA 99 1999 3-3.3.3 and 3-3.3.3.2 identify the most pertinent tests required to be verified.

Facility needs to ensure full compliance with NFPA 99 Chapter 3 and NFPA 70.

Facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.